ISSN: 2578-7683

Case Report

Journal of Dental and Maxillofacial Surgery A Treatment Approach to Unilateral Sinusitis with a Cutaneous Fistula: Case Report on a Complication Involving a Zygoma Quad Restoration Implant

Ventin R1*, Martín S2, Juarez I3, Mesalles A4, Lopez del MJ5 and Piriz RL6 1School of Medicine, Department of Surgery, University of Lleida, Spain 2Primary care Physician, National Health Service, Lleida, Spain 3Oral and Maxillofacial Surgery Staff, University Hospital of Lleida, Lleida, Spain. 4Medical Doctor, University Hospital of Lleida, Lleida, Spain. 5Faculty of , University of the Basque Country, Guipuzcoa, Spain 6Faculty of Medicine, Universidad Complutense de Madrid, Madrid, Spain

*Correspondence: Ramon Ventin Palacin, University Hospital of Lleida, Department of Oral and Maxillofacial Surgery, Rovira Roure 80, 25198 Lleida, Spain, E-Mail: ventin@cirurgía.udl.cat

Received: October 05, 2018; Accepted: November 23, 2018; Published: November 28, 2018

Abstract

The rehabilitation of severely resorbed maxillae containing zygoma implants is a non-grafting treatment option that presents many advantages for patients. It is not, however, free from complications and the most frequent of those reported in the literature is sinusitis. A cutaneous fistula is a less frequent complication, but one that requires more than routine dental treatment and usually calls for maxillofacial surgery. Here, we present the case of a 64-year-old male suffering from sinusitis and with a cutaneous periorbital fistula as a complication; this occurred 8 years after the patient received dental rehabilitation with four zygomatic implants. This clinical report suggests that the trans-sinus of ZIs. Combined with antrostomy, presents satisfactory initial results and is a viable, one stage surgical alternative to treat sinusitis with cutaneous fistula, in the context of a complication involving a fixed dental prosthesis restoration of ZIs.

Keywords: Zygoma implant, Zygoma quad, Implant complications, Sinusitis, Cutaneous fistula.

Abbreviations: CBCT: Cone Beam Computed Tomography; TNLA: Trans nasal Lower Antrostomy; TZIA: Trans-sinusal Zygoma Implant Apicoectomy; ZIs: Zygoma Implants Introduction using ZIs by Brånemark (1998), several authors have made improvements and modifications to the original technique Zygomatic implant therapy was introduced as a way of [3]. The aim of these modifications has been to avoid accomplishing osseointegration in difficult complications and simplify the technique. Hence, Stella & cases without the need for [1]. The procedure Warne (2000) introduced the sinus slot technique in order reduces morbidity, particularly in elderly patients and to exteriorize the implant and thereby avoid the intrasinus those with generally compromised health, in cases in which complications reported in the original technique described bone grafting would otherwise be hazardous. The total by Professor Brånemark [4]. Since then, several authors treatment time and cost are also be reduced in comparison have reported different degrees of technical refinements with traditional rehabilitation therapy such as bone grafts including the exteriorizing of ZIs from the maxilla [5]. [2]. Since the classical description of surgical placement

J Den Max Surg, 1(1): 71-77 (2018) 71 Increasing the number of ZIs used in rehabilitation has also been proposed [6]. The use of immediate loading protocols has been shown to alter previous quality of life scores in treated patients [7]. However, this technique has also produced complications: the probability of a maxillary sinus presenting sinusitis is 2.4%; the chance of soft tissue infection around implants is 2.0%; and the risk of paresthesia of the infraorbital or zygomaticus-facialis nerve is 1% [8].

Figure 2: CBCT image. The aim of this study is to find a conservative approach treatment from the prosthesis point of view to treat severe complications successfully. The total release of implants has been described in the treatment options by the literature, but total function loose and the possibility to create an iatrogenic oro-antral communication difficult to close is the main concern.

Case Report

We present the case of a 64-year-old Caucasian male smoker (consuming more than 10 cigarettes/day) and has type II diabetes. He was under medical treatment with oral hypoglycaemiants and suffered hypertension controlled by medical treatment. The patient had received treatment Figure 3: CBCT- 3D reconstruction. at a private dental clinic, 8 years earlier. He had a fixed bridge supported by four ZIs (Ti-Unite®, Nobel Biocare AB, Göteborg, Sweden). A provisional screwed over-denture was delivered 24 hours after initial surgery.

The patient had not been subjected to any kind of control at the clinic after the definitive dentures were installed 6 months after surgery. The patient came to the emergency unit of our hospital with periorbital erythema and a cutaneous fistula with purulent exudate on the face (Figure 1). CBCT scan were performed (Figure 2, 3) which revealed sinus occupation (Figure 4) and leucocytosis, with 18,000 cells in the routine blood analysis. Orthopantomography (Figure 5). Figure 4: Sinus occupation with purulent exudate.

After 5 days of oral antibiotic treatment, which gave poor results, patient came back again to the hospital showing a spontaneous fistula on the thin palpebral skin, treated with antiseptic topic solution and facial aposit by his primary care physician four days after our antibiotic initial treatment. See the patient at this stage in figure 6.

Figure 1: Facial abscess in the periorbital skin, previous to the spontaneous fistulisation. J Den Max Surg, 1(1): 71-77 (2018) 72 hemisection of the two left-hand implants, to complete the ZIs. Apicoectomy, there by reaching the purulent exudate shown in the image (Figure 7). We then carefully lifted the apical parts of the implants anchored in the periorbital zygomatic bone (Figure 8). The upper implant was removed using diamond-coated premolar forceps (KLS Martin Ergo®, Gebrüder Martin GmbH, Germany). The operation respected the inferior parts of both implants, which were anchored in the left maxillary part of the crestal bone (Figure9).

Figure 5: Orthopantomogram showing the distribution of zygoma quad implants, with left sinusal radiological hyperdensity. Note the superimposed left medial implant with its apex in the orbital fossae.

Figure 7: Subperiosteal view after lifting the mucoperiosteal flap.

Figure 6: 1 day after spontaneous fistulisation on the lower periorbital thin palpebral skin, obtaining a hemo- purulent exudate but the erythema and oedema was persistent around the periorbital region.

The same day a surgical procedure was performed to Figure 8: Trans-sinusal zygoma implant Apicoectomy treat the complication at our oral and maxillofacial unit, (TZIA) made with a surgical (027 in.) round tungsten- under general anaesthesia. carbide bur (Hager & Meisinger GmbH, Neuss, Germany). Purulent sinusal exudate flowed after cutting the implant. The surgical procedure began with a left-sided Caldwell– We cut into both left-sided implants. Luc mucosal incision which respected the infraorbital nerves. An incision was made to lift a full-thickness flap and expose the surgical site in order to access the ZIs in the extrasinus path (Figure 6). With around carbide surgical bur and profuse irrigation we performed a trans-sinus J Den Max Surg, 1(1): 71-77 (2018) 73 weeks during a period of four months patient was visited in our hospital, small scar on the thin sub palpebral skin was note in the healing of the cutaneous fistula from the beginning (Figure 11).

Figure 9: The apical zygoma portion with the adhesion of hemo-purulent exudate to the treated surface of the Figure 11: Facial scar after 6 months of healed the implant (Ti-Unite®Nobel Biocare AB, Göteborg, Sweden). cutaneous fistula, (see the arrow). Note the signs of infection in the holes in the apical implant. Almost every month was performed a control panoramic X-ray. No clinical signs of sinusitis or radiological A trans nasal lower antrostomy (TNLA) was performed hyperdensity were detected with 1 year follow up. in the left maxillary bone accompanied by suction of the purulent exudate in order to re-establish sinus ventilation Discussion and restore normal sinus physiology. We left a gauze with ophthalmic ointment Chlortetracycline hydrochloride The concept of implant periapical pathology was (Oftalmolosacusí® Halcón-Cusí S.A. Barcelona, Spain) in introduced in 1993 by Sussman & Moss, as an infectious- a trans nasal apposite for 48 hours to retard the natural inflammatory disorder of the tissues surrounding the tendency to close and also in order to have a postoperative apex of a dental implant [9]. Ayangco and Sheridan control of potential nasal bleeding. performed periapical surgery over a conventional implant and they also mentioned the possibility of sectioning the implant apex in those cases where complete removal of the granular tissue is not assured, and when the location involves the maxillary sinus or nasal cavity [10].

We hypothesised the cutaneous fistula may be a particular ZIs. Periapical pathology, and that´s why we propose a ZIs. Apicoectomy to treat it, in the same way dental periapical lesions may be treated surgically with dental apicoectomy. However, the cutaneous fistula often exceeds the therapeutic range of conventional dental practice, usually calling for treatment by oral and maxillofacial surgeons, plastic surgeons or

Figure 10: Postoperative panoramic X-ray showing the ENT medical specialists. The main reason for that is the double zygoma implant apicoectomy keeping the dental differential magnitude between an intraoral parulis versus prosthesis functionality and without sinusal hyperdensity an external skin fistula with further aesthetic concerns. The in the post-surgical follow up. zygoma quad implant modality distribution is a particular case in which we opt for double apicoectomy, otherwise We prescribed oral antibiotic post-surgical treatment we do not know which implant is the main responsible of during 8 days (Augmentine® 875-125 mg amoxicillin- cutaneous fistula. clavulanic, GSK AB. Madrid, Spain) every 8 h. Every two-

J Den Max Surg, 1(1): 71-77 (2018) 74 To perform the ZIs. apicoectomy we consider safer The main limitation of our article is that it is a single case the Caldwell-luc approach instead the external approach, report; it would be necessary to do more, similar studies avoiding the aesthetic concerns of potential damage over in order to confirm our results. The absence of a control facial nerve orbital branches, as well as minimizing the group limits the scientific evidence relating to the results facial scar and zygoma bone cortical defect. obtained from our treatment compared to other cases; we must therefore be careful when drawing conclusions. In other hand, sinusitis seems to be the most prevalent Furthermore, few of the published works cited in the postoperative complication associated with ZIs. ranging bibliography refer to the treatment of these complications. from 1.5% to 18.42% [11]. Postoperative complications For this reason, we think that more contributions will with ZIs. include maxillary sinusitis, soft tissue infections, be necessary in this controversial field. However, sinus paresthesia and oro-nasal fistulas [12]. Becktor et al. infections with specific clinical features are more likely to reported a couple of causative factors involved in the recur and we must emphasise that radiographic follow-up physiopathology of sinusitis in the context of a fixed and maintenance protocols are essential since recurrence prosthesis with ZIs. The internal threaded abutment is unpredictable. Further long-term follow-up studies screw chamber of the zygomatic implant seems to create involving larger samples are also needed to confirm these communication between the oral cavity and the antrum, findings. which may result in sinusitis. Another causative factor may be the lack of osseointegration: bone-to-implant contact Conclusions at the margins in the palatal area and functional loading The combination of ZIs. trans-sinus apicoectomy resulting in the transversal mobility of the long coronal part combined with trans nasal lower antrostomy presents of the ZIs. This could imply a greater risk of communication satisfactory initial results and is a viable surgical alternative between the antrum and the oral cavity and thereby cause to treating sinusitis with cutaneous fistula within the sinusitis [13]. context of endosseous zygoma implant fixed restorations. To treat the sinusitis in ZIs. fixed restorations, some Acknowledgements authors consider the antibiotics and/or meatotomies and repositioning the soft tissue without the removal of the This work is original and has not been published stable ZIs [14-16]. If the infection does not resolve with one elsewhere, nor is it currently under consideration for or two rounds of oral antibiotic therapy, there may be a publication elsewhere. concern that the implant is acting as a foreign body and is responsible in part for the persistence of the infection, Authors’ contributions and its removal may be indicated [17]. However, the ZIs extraction creates a compromised premaxilla and may give The authors were involved in the writing of the rise to oroantral communication as well as the functional manuscript and the patient clinical care. All of the authors loosing of dental prostheses [18]. have read and approved the final manuscript.

A conservative approach to keeping dental prostheses Ethics approval and consent to participate functionality is an important issue for the patient. The proposed treatment had one year follow up without Consent for publication: written informed consent any symptom and to totally resolve the problem of the was obtained from the patient for publication of this case cutaneous fistula. report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this The combination of ZIs. Apicoectomy (to eliminate the journal. foreign body that maintains the cutaneous fistula) and trans-nasal inferior antrostomy (to provide a drainage of Competing interests: The authors declare that they sinus) may help to prevent the loss of dental prosthesis have no competing interests. function while also re-establishing normal sinus physiology and ventilation in those cases we find together sinusitis References and cutaneous fistula. This one step surgical treatment is 1. Ahlgren F, Størksen K, Tornes K. A study of 25 located in the middle way between antibiotics/meatotomies zygomatic dental implants with 11 to 49 months’ and total extraction of the implants. follow-up after loading. Int J Oral Maxillofac Implants.

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